# A nurse is caring for a patient who has been receiving olanzapine for schizophrenia. Which assessment finding would be the highest priority concern requiring immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543540 > language: ko > subject: Pharmacology ## 문제 A nurse is caring for a patient who has been receiving olanzapine for schizophrenia. Which assessment finding would be the highest priority concern requiring immediate intervention? ## 보기 1. Temperature of 104°F (40°C) with profuse diaphoresis and muscle rigidity **✔ 정답** 2. Bilateral hand tremor with mild restlessness and pacing 3. Dry mouth, blurred vision, and constipation 4. Drowsiness and orthostatic hypotension **정답: 1** ## 해설 Temperature of 104°F with diaphoresis and rigidity indicates neuroleptic malignant syndrome (NMS), requiring immediate intervention. Other findings like tremor or drowsiness are less urgent side effects of antipsychotics. ## 심화 해설 Clinical Recognition of a Life-Threatening Emergency The correct answer is Temperature of 104°F (40°C) with profuse diaphoresis and muscle rigidity. This cluster of findings represents the classic triad of Neuroleptic Malignant Syndrome (NMS), a rare but potentially fatal idiosyncratic reaction to antipsychotic medications like olanzapine. The priority is immediate intervention because NMS carries a high mortality rate if the offending agent is not discontinued and aggressive supportive care is not initiated [1,4]. Pathophysiology and Clinical Manifestations NMS is believed to result from central dopamine receptor blockade in the hypothalamus and basal ganglia. The sudden blockade leads to: - **Hyperthermia:** Dopamine antagonism in the hypothalamus disrupts the thermoregulatory set point, causing severe, intractable fever [1,4]. - **Autonomic Instability:** Profuse diaphoresis, labile blood pressure, and tachycardia occur due to dysregulation of the autonomic nervous system [4]. - **Severe Muscle Rigidity:** Dopamine blockade in the nigrostriatal pathway results in a "lead-pipe" rigidity, which is a hallmark feature and contributes to hyperthermia through increased muscle activity [4]. The case report by Abegão et al. explicitly describes a patient on olanzapine who developed a "progressive akinetic-rigid syndrome, evolving into severe axial rigidity, autonomic instability, and hyperthermia," mirroring the presentation in this question [4]. Furthermore, NMS can be complicated by rhabdomyolysis due to sustained muscle contraction, leading to elevated creatine phosphokinase (CPK), metabolic acidosis, and acute kidney injury, which necessitates immediate critical care management [4]. Why the Other Options Are Lower Priority While the other options represent common or expected side effects of olanzapine that require nursing assessment and management, they do not constitute an immediate, life-threatening crisis like NMS. - **Option 2 (Bilateral hand tremor with mild restlessness and pacing):** This describes extrapyramidal symptoms (EPS), specifically akathisia and tremor. Although distressing for the patient, these are not acutely life-threatening and can be managed with dose adjustment or adjunctive medication. - **Option 3 (Dry mouth, blurred vision, and constipation):** These are classic anticholinergic side effects of olanzapine. They are common and managed with supportive measures like increasing fluid intake, dietary fiber, and sugarless candies. They do not require emergency intervention. - **Option 4 (Drowsiness and orthostatic hypotension):** These are related to histamine (H1) and alpha-1 adrenergic receptor blockade. Drowsiness is a common early side effect, and orthostatic hypotension is managed with patient education about slow position changes. While a fall risk is present, it is not an immediate medical emergency comparable to NMS. The Critical Nursing Priority The nurse must recognize that a high fever accompanied by muscle rigidity and diaphoresis in a patient on a second-generation antipsychotic is a medical emergency. The immediate nursing actions are to hold the antipsychotic medication, notify the prescriber urgently, and initiate supportive measures including aggressive cooling, fluid resuscitation, and continuous monitoring of vital signs and cardiac rhythm. The concurrence of severe metabolic complications like diabetic ketoacidosis (DKA) is also possible with olanzapine, as noted in the literature, making comprehensive metabolic monitoring essential [1,3]. References (research sources) - [4]Neuroleptic Malignant Syndrome Unmasked: A Case of Extrapyramidal Syndrome With Tardive Dystonia Leading to a Life-Threatening Crisis.Case reportAbegão T, Antão M, Fitas C, Pylyp N, Jordão M. (2025) · DOI: 10.7759/cureus.97056 ## 임상 시나리오 Recognizing Neuroleptic Malignant SyndromeA Life-Threatening Emergency in Antipsychotic Therapy The classic triad of Neuroleptic Malignant Syndrome (NMS) includes hyperthermia (>38°C or 100.4°F), generalized "lead-pipe" muscle rigidity, and autonomic instability (e.g., profuse diaphoresis, labile blood pressure). This is an idiosyncratic reaction to agents like olanzapine, not a dose-related side effect. Immediate intervention is critical as NMS carries a high mortality rate. The first step is to discontinue the offending antipsychotic immediately. Management is primarily supportive care in an intensive care setting, focusing on aggressive cooling, fluid resuscitation, and managing rhabdomyolysis complications. CautionDo not confuse NMS with less urgent conditions like extrapyramidal symptoms (EPS) or anticholinergic effects. A temperature of 104°F (40°C) with rigidity is a medical emergency, not simply a side effect to monitor. ## 핵심 개념 - **Neuroleptic Malignant Syndrome (NMS)** — A rare, life-threatening idiosyncratic reaction to antipsychotics characterized by hyperthermia, severe muscle rigidity, autonomic instability, and altered mental status. - **Extrapyramidal Symptoms (EPS)** — Drug-induced movement disorders including dystonia, akathisia, parkinsonism, and tardive dyskinesia, caused by dopamine blockade in the nigrostriatal pathway. - **Anticholinergic Effects** — Side effects caused by blockade of muscarinic acetylcholine receptors, including dry mouth, blurred vision, urinary retention, constipation, and tachycardia. - **Orthostatic Hypotension** — A drop in blood pressure upon standing, often caused by alpha-1 adrenergic receptor blockade, leading to dizziness and increased fall risk. ## 같은 주제 문제 - [A nurse is assessing a 28-year-old male patient who has been receiving haloperidol for acu…](https://mymerci.kr/pages/nclex_q.php?qn_id=543534) - [A nurse is assessing a patient who has been receiving haloperidol for schizophrenia. 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